Basic Information
| Provider Information | |||||||||
| NPI: | 1700032000 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BRENNAN | ||||||||
| FirstName: | TERESA | ||||||||
| MiddleName: | |||||||||
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| Credential: | R.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 190 E BANNOCK ST | ||||||||
| Address2: | |||||||||
| City: | BOISE | ||||||||
| State: | ID | ||||||||
| PostalCode: | 837126241 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 100 HOSPITAL DR | ||||||||
| Address2: | |||||||||
| City: | KETCHUM | ||||||||
| State: | ID | ||||||||
| PostalCode: | 83340 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2087278800 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/18/2008 | ||||||||
| LastUpdateDate: | 07/21/2022 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 07/21/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 133V00000X | N | Dietary & Nutritional Service Providers | Dietitian, Registered | 133V00000X | 961682 | WA | N | Dietary & Nutritional Service Providers | Dietitian, Registered | 133V00000X | D-1121 | ID | Y | Dietary & Nutritional Service Providers | Dietitian, Registered |
No ID Information.